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Chapter 35: Lower Limb Prosthetic Components: Updated Classiﬁcation and Passive, Body-Powered Components

References

1. Lewis EA: Fluid controlled knee mechanisms clinical considerations. Bull Prosthet Res 1965;24-56.

2. Sawers AB, Hafner BJ: Outcomes associated with the use of microprocessor-controlled prosthetic knees among individuals with unilateral transfemoral limb loss: A systematic review. J Rehabil Res Dev 2013;50(3):273-314 . Medline DOI

3. Torrealba RR, Fernández G, Grieco JC: Towards the development of knee prostheses: Review of current researches. Kybernetes 2008;37(9/10):1561-1576. DOI

4. Prinsen EC, Nederhand MJ, Rietman JS: Adaptation strategies of the lower extremities of patients with a transtibial or transfemoral amputation during level walking: A systematic review. Arch Phys Med Rehabil 2011;92(8):1311-1325. Medline DOI

5. Waters RL, Perry J, Antonelli D, Hislop H: Energy cost of walking of amputees: e inuence of level of

Figure 19

priate prosthetic knee. (Reproduced with permission from Michael JW: Modern prosthetic knee mechanisms. Clin Orthop Relat Res 1999;361:39-47.)

Figure 20

tional rotators. (Courtesy of Ottobock Healthcare, Austin, TX.)

To facilitate this approach, lower limb components can be grouped conceptually into classes based on their clinical performance characteristics.

Illustrations of logic trees to guide clinical decision making in selecting an appro-

Photographs of locking posi-

Figure 21

dynamic elastic response foot with an adjustable heel height. (Courtesy of Freedom Innovations, Irvine, CA.)

Photograph of a carbon ber

Such grouping allows the quick elimination of inappropriate choices. Then the clinic team can focus on identifying the optimal design conﬁguration for the

individual, based on the best available scientiﬁc evidence, client values, and local clinical expertise.

amputation. J Bone Joint Surg Am 1976 ;58(1):42-46. Medline

6. Gailey R, Allen K, Castles J, Kucharik J, Roeder M: Review of secondary physical conditions associated with lower-limb amputation and longterm prosthesis use. J Rehabil Res Dev 2008 ;45(1):15-29. Medline DOI

7. Buckley JG, Spence WD, Solomonidis SE: Energy cost of walking: Comparison of “intelligent prosthesis” with conventional mechanism. Arch Phys Med Rehabil 1997;78(3):330-333.

Medline DOI

8. Datta D, Heller B, Howitt J: A comparative evaluation of oxygen consumption and gait pattern in amputees using Intelligent Prostheses and conventionally damped knee swing-phase control. Clin Rehabil 2005;19(4):398-403. Medline DOI

9. Blumentritt S, Schmalz T, Jarasch R: e safety of C-Leg: Biomechanical

441

Section 3: Lower Limb

tests. J Prosthet Orthot 2009;21(1):2-

15. DOI

10. Highsmith MJ, Kahle JT, Bongiorni DR, Sutton BS, Groer S, Kaufman KR: Safety, energy eciency, and cost ecacy of the C-Leg for transfemoral amputees: A review of the literature. Prosthet Orthot Int 2010;34(4):36237 7. Medline DOI

11. Alimusaj M, Fradet L, Braatz F, Gerner HJ, Wolf SI: Kinematics and kinetics with an adaptive ankle foot system during stair ambulation of transtibial amputees. Gait Posture 2009;30(3):356-363. Medline DOI

12. Wolf EJ, Everding VQ, Linberg AL, Schnall BL, Czerniecki JM, Gambel JM: Assessment of transfemoral amputees using C-Leg and Power Knee for ascending and descending inclines and steps. J Rehabil Res Dev 2012;49(6):831-842. Medline DOI

13. Herr HM, Grabowski AM: Bionic ankle-foot prosthesis normalizes walking gait for persons with leg amputation. Proc Bio Sci 2012;279(1728):457-464.

14. Lehmann JF, Price R, Boswell-Bessette S, Dralle A, Questad K: Comprehensive analysis of dynamic elastic response feet: Seattle Ankle/ Lite Foot versus SACH foot. Arch Phys Med Rehabil 1993;74(8):853-861.

Medline DOI

15. Doane NE, Holt LE: A comparison of the SACH and single axis foot in the gait of unilateral below-knee amputees. Prosthet Orthot Int 1983;7(1):33 -

36. Medline

16. Culham EG, Peat M, Newell E: Below-knee amputation: A comparison of the eect of the SACH foot and single axis foot on electromyographic patterns during locomotion. Prosthet Orthot Int 1986;10(1):15-22. Medline

17. Marinakis GN: Interlimb symmetry of traumatic unilateral transtibial amputees wearing two dierent prosthetic feet in the early

rehabilitation stage. J Rehabil Res Dev 2004;41(4):581-590. Medline DOI

18. Su PF, Gard SA, Lipschutz RD, Kuiken TA: e eects of increased prosthetic ankle motions on the gait of persons with bilateral transtibial amputations. Am J Phys Med Rehabil 2010;89(1):34-47. Medline DOI

19. Paradisi F, Delussu AS, Brunelli S, et al: e conventional non-articulated SACH or a multiaxial prosthetic foot for hypomobile transtibial amputees? A clinical comparison on mobility, balance and quality of life. Scientic World Journal 2015;2015.

Medline DOI

20. Raschke SU, Orendur MS, Mattie JL, et al: Biomechanical characteristics, patient preference and activity level with dierent prosthetic feet: A randomized double blind trial with laboratory and community testing. J Biomech 2015;48(1):146-152.

Medline DOI

21. Campbell JW, Childs CW: e SAFE foot. Orthot Prosthet 1980;34(3):3-16.

22. Hafner BJ, Sanders JE, Czerniecki J, Fergason J: Energy storage and return prostheses: Does patient perception correlate with biomechanical analysis? Clin Biomech (Bristol, Avon) 2002;17(5):325-344. Medline DOI

23. Hansen AH, Sam M, Childress DS: e eective foot length ratio: A potential tool for characterization and evaluation of prosthetic feet. J Prosthet Orthot 2004;16(2):41-45.

DOI

24. Gard SA, Konz RJ: e eect of a shock-absorbing pylon on the gait of persons with unilateral transtibial amputation. J Rehabil Res Dev 2003;40(2):109-124. Medline DOI

25. Segal AD, Orendur MS, Czerniecki JM, Shofer JB, Klute GK: Transtibial amputee joint rotation moments during straight-line walking and a common turning task with and without a torsion adapter.

J Rehabil Res Dev 2009;46(3):375-383.

Medline DOI

26. Sowell TT: A preliminary clinical evaluation of the Mauch hydraulic foot-ankle system. Prosthet Orthot Int 1981;5(2):87-91. Medline

27. Williams R: Adaptable prosthetic foot and ankle mechanism for sloped walking. Available at: http://www.

resna.org/sites/default/les/legacy/ conference/proceedings/2008/SDC/ Williams.html. Accessed September

29, 2015.

28. De Asha AR, Johnson L, Munjal R, Kulkarni J, Buckley JG: Attenuation of centre-of-pressure trajectory uctuations under the prosthetic foot when using an articulating hydraulic ankle attachment compared to xed attachment. Clin Biomech (Bristol, Avon) 2013;28(2):218-224.

Medline DOI

29. Portnoy S, Kristal A, Gefen A, SievNer I: Outdoor dynamic subject-specic evaluation of internal stresses in the residual limb: Hydraulic energy-stored prosthetic foot compared to conventional energy-stored prosthetic feet. Gait Posture 2012;35(1):121-

125. Medline DOI

30. Sedki I, Moore R: Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013;37(3):250-

254. Medline DOI

31. Hicks R, Tashman S, Cary JM, Altman RF, Gage JR: Swing phase control with knee friction in juvenile amputees. J Orthop Res 1985;3(2):198-

201. Medline DOI

32. Radclie CW: Four-bar linkage prosthetic knee mechanisms: Kinematics, alignment and prescription criteria. Prosthet Orthot Int 1994;18(3):159-

173. Medline

33. Gard SA, Childress DS, Vellendahlt JE: e inuence of four-bar linkage knees on prosthetic swing-phase oor clearance. J Prosthet Orthot 1996;8:34-40. DOI

442

Chapter 35: Lower Limb Prosthetic Components: Updated Classiﬁcation and Passive, Body-Powered Components

34. Blumentritt S, Scherer HW, Wellerschaus U, Michael JW: Design principles, biomechanical data and clinical experience with a polycentric knee oering controlled stance phase knee exion: A preliminary report. J Prosthet Orthot 1997;9(1):18-24.

35. Sutherland J, Sutherland D, Kaufman K, Teel M: Case study forum: Gait comparison of two prosthetic knee units. J Prosthet Orthot 1997;9:168-

173. DOI

36. Devlin M, Sinclair LB, Colman D, Parsons J, Nizio H, Campbell JE:

Patient preference and gait eciency in a geriatric population with transfemoral amputation using a free-swinging versus a locked prosthetic knee joint. Arch Phys Med Rehabil 2002;83(2):246-249.

Medline DOI

37. Irolla C, Rheinstein J, Richardson R, Simpson C, Carroll K: Evaluation of a graduated length prosthetic protocol for bilateral transfemoral amputee prosthetic rehabilitation. J Prosthet Orthot 2013;25(2):84-88. DOI

38. Geil M, Coulter C: Analysis of locomotor adaptations in young children with limb loss in an early prosthetic knee prescription protocol. Prosthet Orthot Int 2014;3 8(1):5 4 - 61.

Medline DOI

39. Mauch HA: Stance control for aboveknee articial legs-design considerations in the SNS knee. Bull Prosthet Res 1968;10:61-72.

40. Michael JW: Modern prosthetic knee mechanisms. Clin Orthop Relat Res 1999;361:39-47. Medline DOI

443

Chapter 36

Lower Limb Prosthetic Components: Microprocessor-Controlled Components

Phillip M. Stevens, MEd, CPO, FAAOP John W. Michael, MEd, CPO, FAAOP

Abstract

Lower limb prosthetic systems in current use are increasingly characterized by components that are regulated by internal microprocessors, which can control passive joint characteristics and active joint movements at both the knee and the ankle. e previously limited number of commercially available microprocessor-controlled components continues to increase with more prototype devices being described in the current prosthetic literature. e benets of these technologies are still being determined, but they appear to include increased condence and security, reduced cognitive loading, improved energy eciency, and increased self-selected walking speeds.

Keywords: external power; lower limb prosthesis; microprocessorcontrolled; microprocessor-regulated, prosthetic components

Introduction

Microprocessors were ﬁrst introduced into prosthetic components in 1990 and have been increasingly used since that time. This chapter focuses on both currently available and developing prosthetic technologies that use microprocessor regulation. Several key terms in this chapter require a deﬁnition. The term microprocessor-controlled (MPC) refers to components that are intelligently regulated in real time by one or more onboard microprocessors that modify some characteristic of their behavior according to either environmental or user inputs. Passive MPC components refer to components in which the passive resistance characteristics of the named joint are moderated according to these inputs. Active apropulsive MPC components refer to components capable

Mr. Stevens or an immediate family member serves as a paid consultant to or is an employee of Hanger Clinic, and ser ves as a board member, owner, ocer, or committee member of the American Academy of Orthotists and Prosthetists. Neither Mr. Michael nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

of producing nonpropulsive movement around a joint axis, creating movement of elements within the prosthesis but incapable of propelling the end user’s body weight. Active propulsive MPC components refer to components that respond to environmental or user inputs by creating powered movements capable of propelling the user’s body against gravitational forces.

Passive MPC Prosthetic Knee Mechanisms

The large-scale incorporation of commercially available MPC prosthetic components began with passive MPC prosthetic knee mechanisms. Prior to the implementation of microprocessors, the dampening characteristics of prosthetic knee mechanisms were commonly regulated by hydraulic cylinders.

These hydraulic mechanisms were engineered to control the resistance of the knee during the swing phase of gait, the stance phase of gait, or both. tive passive resistance characteristics of such knees are adjusted by the prosthetist to match the needs of individual patients according to such factors as their limb strength and preferred walking speed. However, these resistance values can be optimized only within a modest range of walking speeds.4 Thus, if an individual walks faster than the gait speed used when the resistance parameters for the knee were set, these resistance values might be experienced as inadequate, allowing excessive heel rise in the swing phase and causing the individual to wait on the prosthesis. In contrast, if an individual walks slower, resistance values could be experienced as excessive, creating a relatively stiff knee.

In the ﬁrst generation of passive MPC knee mechanisms, the resistance values of the knee during the swing phase of gait could be set to relative values consistent with the user’s self-selected, fast, and slow walking speeds.4 Sensors within the knee unit recorded the speed of knee ﬂexion during gait, allowing an onboard microprocessor to vary the swing resistance of the knee in real time with the user’s gait speed. Second-generation devices, beginning with the C-leg (Ottobock), expanded the role of the microprocessors, allowing variation of both swing and stance phase knee resistance in real time according to environmental inputs.4 In addition to adapting the knee resistance to variable walking speeds, these second-generation MPC knee

1-3

The rela-

445

Section 3: Lower Limb

Figure 1

sive microprocessor-controlled knee mechanism. (Courtesy of Ottobock, Austin, TX.)

Photograph of the C-leg, a pas-

joints could recognize aberrant movements that might suggest a stumble and modulate the resistance to knee ﬂexion accord i ngly.

Early research inquiries on passive MPC knees tended to focus on questions of energy consumption and efﬁciency.

5,6

This led to the erroneous impression that the beneﬁts of MPC knees could only be experienced by young and active amputees.7 Subsequent research efforts began to focus on such issues as balance, conﬁdence, stumbles, falls, cognitive loads during ambulation, and the negotiation of environmental obstacles.

8,9

With this shift in focus, it became clear that many of the beneﬁts associated with the use of MPC knees could also be experienced by older patients who may not initially present with the ability to ambulate at elevated walking speeds.

9-13

There are now nearly two decades of research on passive MPC knee mechanisms, with the bulk of that research conducted on the C-leg (Figure 1) and the C-leg Compact (Ottobock). In aggregate, this research suggests that the greatest value of these devices to end users may be observed in decreases in

Figure 2

passive microprocessor-controlled foot-ankle mechanism. (Courtesy of Endolite, Hampshire, UK.)

Photograph of the élan foot, a

stumbles and falls, decreased perceived cognitive burden during ambulation, and increases in self-reported mobility and well-being.

14,15

Passive MPC Prosthetic Foot-Ankle Mechanisms

More recently, the concept of regulating passive joint resistance has been applied to foot-ankle mechanisms with a renewed interest in hydraulically regulated ankle motion. The loads experienced by the residual limb within the prosthetic socket vary according to walking surfaces, with higher localized loads often observed during descending tasks.16 The use of hydraulic foot-ankle systems among patients with transtibial amputations has been shown to decrease the loading rates experienced at the distal tibia across a range of walking tasks and surfaces and provide a generally smoother gait. modulated knee systems, ideal hydraulic resistance at the ankle will vary according to patient preferences, ambulatory speed, and the slope of the walking surface.18 Hydraulic settings reﬁned for walking on level ground may prove less ideal when navigating sloped terrains.

17-19

As with hydraulically

During hill ascent, increased resistance to plantar ﬂexion and decreased resistance to dorsiﬂexion may facilitate a more normal gait pattern. In contrast, descent may be safer and more stable with decreased hydraulic resistance to plantar ﬂexion and increased resistance to dorsiﬂexion.

20,21

Within passive MPC prosthetic foot-ankle mechanisms, such as the élan foot (Endolite) and the Raize foot (Fillauer), onboard sensors are able to determine the slope of the walking surface and adapt the hydraulic resistance of the ankle in real time21 (Figure 2).

Adapting ankle position according to environmental demands represents one strategy for passive MPC prosthetic foot-ankle mechanisms. In an alternative strategy, referred to as the ankle mimicking prosthetic foot or AMP foot

1.0 (developed by Vrije Universiteit in Brussels, Belgium), the objective is to obtain a targeted, focused release of the energy conserved throughout the stance phase at the moment of push-off.22 The ankle mimicking prosthetic foot design does not draw on external power to create propulsive forces; rather, it reﬁnes the concept of an energy-storing foot by harvesting energy throughout the stance phase of gait and releasing it through a more physiologic range of plantar ﬂexion at the moment of push-off as determined by an onboard microprocessor.

Active Apropulsive MPC Prosthetic FootAnkle Mechanisms

During ambulation, the ankle experiences swing phase dorsiﬂexion to assist in limb clearance. The PROPRIO FOOT (Össur) represents an active apropulsive MPC foot-ankle system in which swing phase dorsiﬂexion is provided through the application of external power to a drive motor23 (Figure 3). This movement can also be used to adapt the ankle position during sitting (by adjusting to an alignment of relative plantar ﬂexion to better mimic

446

Chapter 36: Lower Limb Prosthetic Components: Microprocessor-Controlled Components

Figure 3

FOOT, an active apropulsive microprocessor-controlled foot-ankle mechanism. (Courtesy of Össur, Reykjavik, Iceland.)

Photograph of the PROPRIO

able-bodied ankle behavior) and across variable heel heights (by adopting increasing angles of relative plantar ﬂexion with increasing heel height). It is also capable of actively adapting to surfaces with variable inclines and declines. The effects of this mechanism on ambulation are still uncertain, with preliminary studies suggesting inconsistent effects on self-selected walking speeds and energy costs during ambulation.

24-26

Patients have described both a feeling of increased safety and decreased perceived exertion during ramp descent.

20,26

During stair ascent, the additional dorsiﬂexion mobility of the prosthetic limb appears to reduce the impact on the sound limb.

Active Propulsive MPC Prosthetic FootAnkle Mechanisms

More recently, developers of foot- ankle prostheses have been challenged to address the propulsive deﬁcits encountered in the absence of concentric contractions across the major joints of the lower limbs. Most of the propulsion of the able-bodied lower limb is derived from the concentric activity of the plantar ﬂexors during push-off.27 Given that the ankle generates 3 to 5 times the energy it absorbs during walking

Figure 4

active propulsive microprocessor-controlled foot-ankle me chanism. (Courtesy of BiOM, Bedford, MA; photographer Jimmy DeVarie, BiOM.)

on level ground,

Photograph of the BiOM T2, an

28,29

this deﬁcit can be only partially addressed in prosthetic feet with nonpowered energy storage and return.

30, 31

Several approaches are being explored to provide propulsive movement at the prosthetic ankle joint. In the ﬁrst commercially available, externally powered, propulsive MPC foot-ankle prosthetic design, the BiOM foot (BiOM), battery-powered electronic drive motors coupled with parallel, mechanical springs are used to mimic the push-off behavior of the plantar ﬂexors

32,33

(Fig- ure 4). The preliminary beneﬁts identiﬁed with this system include reduced energy consumption in gait, increased self-selected walking speeds, and decreased loading of the sound side limb at the moment of prosthetic push-off in

33-36

gait.

In addition to the BiOM foot, several alternative designs are in various stages of development. In a device that uses a spring ankle with regenerative kinetics (known as SPARKy), robotic tendon actuators enhance the energy stored by helical springs mounted posterior to a prosthetic ankle joint (Figure 5). As these springs elongate during ankle dorsiﬂexion, low-energy motors mounted in series with the springs draw on an external power source to further deﬂect

Figure 5

kle (SpringAc tive). Its design was derived in par t from research using a spring ankle with regenerative kine tics. (Courtesy of Spr ingActive, Tempe, AZ; photographer Philipp Pasolli.)

Photograph of the Odyssey An-

them, thus augmenting their propulsive forces at the time of push-off.

37, 38

In a related approach, the ankle

mimicking prosthetic foot or AMP foot

2.0 (developed by Vrije Universiteit in Brussels, Belgium) uses two elastic springs. A spring for plantar ﬂexion is located within the foot and stores energy throughout the controlled dorsiﬂexion of gait. A second push-off spring is mounted posteriorly to the prosthetic ankle joint where it is progressively loaded by an externally powered electric actuator throughout the stance phase. A locking mechanism stores the energy of the system until the moment of push-off, when it is released.

Efforts also have been described in which pneumatic bladders are inﬂated to mimic the contractile activity of muscle bellies.

40- 42

However, the effectiveness of these pneumatic systems has been limited because of their current need to be tethered to an external source of pressurized air.

Active Propulsive MPC Prosthetic Knee Mechanisms

Unlike the ankle, which acts primarily as an energy generator during walking

447

Section 3: Lower Limb

Figure 7

sive microprocessor-controlled knee-anklefoot mechanism. (Copyright Michael Goldfarb, PhD and Cognizant Communication, Putnam Vall ey, NY.)

Photograph of an active propul-

and ankle separately, an approach has been described in which a powered knee and powered ankle are coupled together within the same prosthesis.

48,4 9

Extensively described within the literature, prototypes of the Vanderbilt knee (developed by Vanderbilt University in Nashville, TN) suggest substantial increases in self-selected walking velocity, decreases in the energy costs of ambulation, and improved biomechanics during the negotiation of stairs and

49-51

ramps

(Figure 7). Although early in their development, alternative energyefﬁcient approaches are being investigated in which the energy absorbed at the knee during stance ﬂexion is stored and transferred to the ankle to provide a propulsive push-off.

52,53

Figure 6

KNEE, an active propulsive microprocessorcontrolled k nee mechanism. (Courte sy of Össur, Reykjavik, Iceland.)

Photograph of the POWER

on level ground, the knee joint is better characterized by its energy absorption capabilities.29 Prosthetic replication of knee joint function has historically focused on the resistance provided by hydraulic cylinders and elastomeric bumpers. However, during certain tasks, such as ascending sloped terrain or stairs and sit-to-stand transfers, the knee acts as a net power generator.

Early attempts at providing powered propulsion at the knee joint have been based on the battery-driven drive motors of the POWER KNEE (Össur) (Figure 6). Early evidence is limited but suggests potential advantages in limb symmetry during sit-to-stand trans-

43,44

fers

and sparing of the limb on the

sound side during step-over-step stair

ascent.

An alternative approach has been suggested in which elastic actuators are coupled antagonistically to store and release the energy of the knee throughout the gait cycle in a more conservative fashion.46 Such a system would be nearly energy neutral during walking on level ground, thereby reducing the weight and capacity of the external battery source. However, the system would be capable of positive energy production during ascending tasks, with an associated increased reliance on the externally powered actuators of the system.

As with active propulsive MPC prosthetic foot-ankle mechanisms, pneumatic artiﬁcial muscle systems have been suggested as a potential source of propulsive force.47 However, this effort is currently conﬁned to laboratory prototypes and limited by the current requirement that it be tethered to an external source of power.

Active Propulsive MPC Prosthetic Knee-FootAnkle Mechanisms

In addition to the current efforts to provide propulsive power at the knee

Myoelectric Control of Powered Movement

The MPC components described to this point rely on input gathered from sensors embedded within the components themselves. Using angular velocities as measured at the mechanical joints or load sensors positioned within the prosthesis, the various microprocessor mechanisms interpret this input to infer the needs of the end user and accordingly adapt the passive or propulsive characteristics of the prosthesis. An alternative approach, which is receiv ing increased attention in the current literature, involves user-generated inputs in the form of myoelectric signals generated at the residual limb to trigger active movement of the prosthesis.

Transfemoral amputees have demonstrated successful myoelectric control of virtual lower limb prosthetic devices. This was followed by successful ambulatory control of externally powered prototype prostheses, with control provided by myoelectrodes positioned underneath the interface liners in transtibial applications and within the socket wall of a transfemoral prosthesis. recently, a case study has suggested the potential beneﬁts of further enhancing

56,57

54,55

448

Chapter 36: Lower Limb Prosthetic Components: Microprocessor-Controlled Components

the functionality of externally powered lower limb prostheses by coupling targeted muscle reinnervation techniques with more elaborate myoelectric control systems.58 Preliminary investigation suggests that, within transfemoral applications, patients may experience greater comfort and fewer motion artifacts when electrodes are mounted within the interior socket wall of a skin-ﬁt, suction suspension socket.

Summary

In addition to the wealth of non–MPC components that continue to meet the basic needs of many individuals with lower extremity limb loss, many modern prosthetic components derive functional beneﬁts from microprocessor regulation. These components range from passive devices, which change the joint resistance values in real time to adapt to the immediate needs of the end user, to active propulsive devices capable of drawing energy from an external power source to create propulsive movements. Within this range of MPC components, the functional beneﬁts are not yet fully deﬁned but appear to have the poten

tial for enhanced safety and conﬁdence, reduced energy consumption, and decreased reliance on compensatory gait strategies. Continued research and development will better deﬁne these beneﬁts within the prosthetic healthcare delivery system and improve the functional abilities of the end users.

References

1. Silver-orn MB, Glaister CL: Functional stability of transfemoral amputee gait using the 3R80 and Total Knee 2000 prosthetic knee units. J Prosthet Orthot 2009;21:18-31. DOI

2. Mauch HA: Stance control for aboveknee articial legs: Design considerations in the S-N-S knee. Bull Prosthet Res 1968;10:61-72.

3. Staros A: e principles of swingphase control: e advantages of uid

mechanisms. Prostheses Braces Tech Aides;1964;13:11-16.

4. Michael JW: Modern prosthetic knee mechanisms. Clin Orthop Relat Res 1999;361:39-47. Medline DOI

5. Kirker S, Keymer S, Talbot J, Lachmann S: An assessment of the intelligent knee prosthesis. Clin Rehabil 1996;10:267-273. DOI

6. Schmalz T, Blumentritt S, Jarasch R: Energy expenditure and biomechanical characteristics of lower limb amputee gait: e inuence of prosthetic alignment and dierent prosthetic components. Gait Posture 2002;16(3):255-263. Medline DOI

7. Johansson JL, Sherrill DM, Riley PO, Bonato P, Herr H: A clinical comparison of variable-damping and mechanically passive prosthetic knee devices. Am J Phys Med Rehabil 2005;84(8):563-575. Medline DOI

8. Hafner BJ, Willingham LL, Buell NC, Allyn KJ, Smith DG: Evaluation of function, performance, and preference as transfemoral amputees transition from mechanical to microprocessor control of the prosthetic knee. Arch Phys Med Rehabil 2007;88(2):207-217. Medline DOI

9. Kahle JT, Highsmith MJ, Hubbard SL: Comparison of nonmicroprocessor knee mechanism versus C-Leg on Prosthesis Evaluation Questionnaire, stumbles, falls, walking tests, stair descent, and knee preference. J Rehabil Res Dev 2008 ;45 (1):1-14.

Medline DOI

10. Hafner BJ, Smith DG: Dierences in function and safety between Medicare Functional Classication Level-2 and -3 transfemoral amputees and inuence of prosthetic knee joint control. J Rehabil Res Dev 20 09;46(3):417-433. Medline DOI

11. eeven P, Hemmen B, Rings F, et al: Functional added value of microprocessor-controlled knee joints in daily life performance of Medicare Functional Classication

Level-2 amputees. J Rehabil Med 2011;43(10):906-915. Medline

12. Burneld JM, Eberly VJ, Gronely JK, Perry J, Yule WJ, Mulroy SJ: Impact of stance phase microprocessorcontrolled knee prosthesis on ramp negotiation and community walking function in K2 level transfemoral amputees. Prosthet Orthot Int 2012;36(1):95-104. Medline DOI

13. Eberly VJ, Mulroy SJ, Gronley JK, Perry J, Yule WJ, Burneld JM: Impact of a stance phase microprocessor- controlled knee prosthesis on level walking in lower functioning individuals with a transfemoral amputation. Prosthet Orthot Int 2013. Medline

14. Highsmith MJ, Kahle JT, Bongiorni DR, Sutton BS, Groer S, Kaufman KR: Safety, energy eciency, and cost ecacy of the C-Leg for transfemoral amputees: A review of the literature. Prosthet Orthot Int 2010;34(4):36237 7. Medline DOI

15. Sawers AB, Hafner BJ: Outcomes associated with the use of microprocessor- controlled prosthetic knees among individuals with unilateral transfemoral limb loss: A systematic review. J Rehabil Res Dev 2013;50(3):273-314 . Medline DOI

16. Portnoy S, van Haare J, Geers RP, et al: Real-time subject-specic analyses of dynamic internal tissue loads in the residual limb of transtibial amputees. Med Eng Phys 2010;32(4):312-

323. Medline DOI

17. Portnoy S, Kristal A, Gefen A, SievNer I: Outdoor dynamic subjectspecic evaluation of internal stresses in the residual limb: Hydraulic energy-stored prosthetic foot compared to conventional energy- stored prosthetic feet. Gait Posture 2012;35(1):121-

125. Medline DOI

18. De Asha AR, Johnson L, Munjal R, Kulkarni J, Buckley JG: Attenuation of centre-of-pressure trajectory uctuations under the prosthetic foot

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Section 3: Lower Limb

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